Provider Demographics
NPI:1568792141
Name:NUSSBAUM, KATHLEEN (ANP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:NUSSBAUM
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 REZANOF DR E
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6602
Mailing Address - Country:US
Mailing Address - Phone:907-486-3281
Mailing Address - Fax:
Practice Address - Street 1:1915 REZANOF DR E
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6602
Practice Address - Country:US
Practice Address - Phone:907-486-3281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-05
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1288363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1578402Medicaid